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Tool that might be used to improve the trauma system in the region
Witaya Chadbunchachai
Trauma and Critical Care Center
Khon Kaen Regional Hospital
Risk chance
Industrial hazard
terrorism
earthquake
Thailand risk areaThailand risk area””landslide
Thai EMS situation observed by the Swedish EMS mission team during Tsunami catastrophe :-
1. Weak coordination at a national level 2. Inadequate dispatch center at regional and local level 3. The need for a national emergency phone number; known
to the public 4. Poor training of rescue foundation staff as well as no
certification of volunteers 5. Non specialized and non standardized training for EMS
personnel 6. No or insufficiently developed helicopter, sea rescue 7. Weak emergency rescue procedures and standards
• “It couldn’t happen to us”
is an un acceptable excuse for being ill prepared to deal with a major incident.
T.J. Hodgetts
K. Mackway-Jones
เพราะเชื่��อว่�า “เหตุ�การณ์�อย่�างนี้��ไม่�เก�ดขึ้��นี้ในี้บ้ านี้ขึ้องเราหรอก”
ก!เลย่ไม่�คิ�ดที่��จะเตุร�ย่ม่การร&บ้ม่�อก&บ้สถานี้การณ์� คิว่าม่เชื่��อนี้��เป็*นี้คิว่าม่เชื่��อที่��ใชื่ ไม่�ได และร&บ้ไม่�ได
Development Frame : An Development Frame : An Inclusive Trauma Care Inclusive Trauma Care SystemSystem • PREVENTION
• TRAINING
• EVALUATION
AllInjuredPatients
MajorTraumaPatients
PREHOSPITAL• Communication• Medical Direction• Triage• Transport
ACUTE CARE FACILITY WITHIN A TRAUMA
SYSTEM other injured patients
TRAUMA CENTER most severity injured or
SPECIALTY CARE FACILITY peds, burns, and so on
INTERFACILITYTRANSFER
REHABILITATION
Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, MD, 1992
Trauma RegistryTrauma Registry
ObjectiveObjective
To establish data base to monitor and modify To establish data base to monitor and modify trauma care systemtrauma care system
To define nature and extend of trauma for To define nature and extend of trauma for preventionprevention
To define factors for patients mortality and To define factors for patients mortality and morbiditymorbidity
To determine manpower requirement To determine manpower requirement
To estimate expendituresTo estimate expenditures
Ideal Character of Injury Surveillance System
Ideal Character of Injury Surveillance System
1.1. UsefulnessUsefulness
2. The quality of surveillance2. The quality of surveillanceSimplicitySimplicityFlexibilityFlexibility
AcceptabilityAcceptabilitySensitivitySensitivity
Positive predictive valuePositive predictive valueRepresentativeRepresentative
TimelinessTimeliness
3. Validation of Data Collection Methods3. Validation of Data Collection Methods
4. Reliability of The Coding System4. Reliability of The Coding System
Ideal Character of Injury Surveillance System
Ideal Character of Injury Surveillance System
Key Components
Team work Work sites Data collection equipment Data Collection form Data collection program with a data entry
manual Data flow system Data analysis and report
Work site at Work site at Registration UnitRegistration Unit
Work siteWork site at ERat ER
Work site at Work site at ERER
Minimal Basic Data SetMinimal Basic Data Set
Modified from Modified from
* Text Book of Trauma* Text Book of Trauma
Champion & FelicianoChampion & Feliciano
Chapter 2 Trauma ScoringChapter 2 Trauma Scoring
Minimal Basic Data SetMinimal Basic Data Set
Modified from Modified from
* Text Book of Trauma* Text Book of Trauma
Champion & FelicianoChampion & Feliciano
Chapter 2 Trauma ScoringChapter 2 Trauma Scoring
• Minimal basic data set– Hospital identifier No.– Hospital patient No.– Age– Sex– Race/Ethnic origin– E-code– Transferring hospital– Transferred to, from or not transferred– Date of Admission– Time of Admission
American College of SurgeonAmerican College of SurgeonAmerican College of SurgeonAmerican College of Surgeon
• On arrival in ER– Systolic BP, pulse, RR, GCS
• In OR– CPT, code, date, time, surgeon, identifier
• Diagnosis– ICD – 9 (List)
• Disposition– Died (Yes or No)– Date of discharge– Disposition if alive
American College of SurgeonAmerican College of SurgeonAmerican College of SurgeonAmerican College of Surgeon
Data Recording Form
Injury Surveillance Record Hospital name …………..…………… Province………………………..…...
Present 1 In this province address 2 Not in this province
3 Unknown First name…………………….…….Last name…………….… HN…………………………Sex 1 Male 2 Female Date of Birth……………..…or Age ………….. Yr …...... Month. Or Approximately ….… Yr.Occupation 01 Govt. Officials 02 Police/Soldier 03 Govt. enterprise 04 Private company
05 Unskilled worker 06 Business 07 Agriculture 08 Students others……….
Date occurred ……………………………….…..Time occurred ………………………Date arrived at hospital……………..………Time arrived at hospital………..……Location District……………………………….Province………………………………… 1 Home 2 Residential institution 3 School, Public Admin Area 4 Sport, athletic area 5 Street/Hi-way 6 Trade and service area 7 Industrial and construction area 8 Farm 9 Others………………
Intention 1 Accident 2 Self-harm 3 Assault Unknown
OccupationalInjury 1 Yes 0 No Unknown
External causes of injury 1 Transport accidents 1.1 Type of injured person 1 pedestrian 2 Driver 3 Occupants 4 Unknown 1.2 Vehicle of the injured 1 Bi/tricycle 2 Motorcycle 3 Motor-tricycle 4 Personal car 5 Pick up/Van 6 Heavy truck 7 Trailer-Truck 8 Mini-Bus 9 Buses 10 Others (Specified)……………………………… 1.3 Injured due to 20 Fall from vehicle 21 Vehicle over turned, sank etc. Collision with…………….............. Others (Specified)……………… 2 Others injuries (Specified) ………………………………………………………………………………… 3 Unknown
Risk behaviors
1. Alcohol 1 Use 0 Not use Unknown
3. Seat belt 1 Use 0 Not use Unknown
2. Drugs/ Medication 1 Use (Specified)
………………….. 0 Not use Unknown
4. Helmet 1 Use 0 Not use Unknown
Transportation of the injured to hospital 1 From injured Person who transport No Not known Site or others 1 EMS 2 Charitable Volunteers……………………………………..
3 Police
Others…………………………………………………………….. 2 From health facility: Name ……………….….Province…………. 2.1 By Ambulance With person to take care (specified professional)
……………. 1. No person taking care 0 Not ambulance 2.2 With referral letters 1 Yes 0 No
First aid / care while transport
Breathing care 1 Yes-appropriate 2 Yes but not appropriate 3 Not needed 0 No
Bleeding care 1 Yes-appropriate 2 Yes but not appropriate 3 Not needed 0 No
Splint / Slab 1 Yes-appropriate 2 Yes but not appropriate 3 Not needed 0 No
IV fluid 1 Yes-appropriate 2 Yes but not appropriate 3 Not needed 0 No
Seen At. ER (Record only patients who are to be R/O Head injury / Observe / Admit / Dead at ER., Refer) Vital sign BP…………….........mm/Hg Pulse ……......………/ min R.R ………………………. / minConsciousness description...............................................................................................Coma Scale ..........................................
Type of injury cause 1 Blunt 2 Penetrating 3 Blunt and penetrating Others
Date Disposition from ER. ……………………………………………………………………….Time……………………………….By 1 D.B.A. 2 D/C 3 Refer 4 Against advice 5 escape 6 Dead at ER. 7 Admission to …………….
DIAGNOSIS (Specified organ and injury in detail) If admitted, do not fill at ER.1………………………………………..(BR………AIS……..) 4………………….………………..(BR………AIS……..)2………………………………………..(BR………AIS……..) 5………………….………………..(BR………AIS……..)3………………………………………..(BR………AIS……..) 6………………….………………..(BR………AIS……..)
Date Discharged from ward ……………………………………………………………………………Outcome 1 Improve 2 Refer 3 Against advice 4 Escape 5 Dead 6 Ask to go back to die at home
Recorders name………………………………………………………………………………
Fourth Phase (1999)Fourth Phase (1999)
Trauma PatientsTrauma Patients Data collection by ER nurseData collection by ER nurseAnd trauma center clerkAnd trauma center clerk
Immediate key in on scene at ERImmediate key in on scene at ERBy trauma center clerk By trauma center clerk
DischargeDischarge AdmitAdmit
Summarized form for Dx, BR, Summarized form for Dx, BR, AIS and key in byAIS and key in by
trauma center nurse at trauma center nurse at Trauma Center Office Trauma Center Office
Analysis by IS output Analysis by IS output program and trauma program and trauma center programmer center programmer
Documents
Number of Injury Classified by Type
7392 7349
10020 10504 10965
133751370513071
15140
1670217903
1877320091
23268 2282623500
6954 7615 7883 8269 91269893
9316 9452
6313
77916117
13510 14048
9087
0
5000
10000
15000
20000
25000
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Cases
Traffic Others Total
50
Number of Dead Classified by Type
291 294
352
271
327 331
412 409434
366
40 44
93112 107 109 126 135 151 140
331 338
445
383
434 440
538 544585
506
0
100
200
300
400
500
600
700
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Cases
Traffic Others Total
Age and Sex of Injury 2005
2030 (63%)
1194 (37%)
3894 (72%)
1513 (28%)
4218 (74%)
1512 (26%)
2470 (70%)
1077 (30%)
1749 (68%)
841 (32%)
985 (62%)
593 (38%)488 (60%)
323 (40%)286 (47%)327 (53%)
0
500
1000
1500
2000
2500
3000
3500
4000
4500No
<10 10 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 >70 Age
Male Female
Type of External Cause of Injury 2005Type of External Cause of Injury 2005
9452 (96%)
366 (4%)
3111 (99%)
38 (1%)
4230 (100%)
8
2747 (100%)
1
2433 (99%)
31 (1%)0
2000
4000
6000
8000
10000
Traffic Fall Inanimate Force Animate Force Assualt
No Dead
Organ Injury of the Admitted Case 2005Organ Injury of the Admitted Case 2005
3391 (91%)
335 (9%)
856 (98%)
2 (2%)
925 (100%)
4
901 (97%)
31 (3%)
1277 (90%)
137 (10%)
0
500
1000
1500
2000
2500
3000
3500
Head Wrist&Hand Multiple Inj.
No DEAD
Dead of Organ Injury and External Cause of Injury 2005
Dead of Organ Injury and External Cause of Injury 2005
314 (82%)
38 (10%)26 (7%)
5 (1%)
150 (91%)
5 (3%)_9 (5%)1 (1%)
68 (88%)
1 (1%)8 (11%)0
0
50
100
150
200
250
300
350
Traffic Fall Assualt
Head MultipleThorax Abdomen
Day in Week of Injury 2005Day in Week of Injury 2005
3155 (98%)
63 (2%)
3193 (98%)
66 (2%)
3169 (98%)
59 (2%)
3171 (97%)
83 (3%)
3457 (98%)
68 (2%)
3823 (98%)
89 (2%)
3572 (98%)
78 (2%)0
500
1000
1500
2000
2500
3000
3500
4000
Mon Tue Wed Thu Fri Sat Sun
No. Dead
10,946 (47%)7,999 ( 34%)
4,555 (19%)
0.00-08.00 am 08.00 am.-04.00 pm. 04.00 -12.00 pm.
Time of Arrival 2005Time of Arrival 2005
24.4626.5516.36 17 17.39
20.726.48
35.39
0
10
20
30
40
19981999200020012002200320042005
Helmet Use of Motorcycle Rider with Traffic Accident in Khon Kaen Municipality
%
41.42 38.74 37.09 34.6531.71
36.61
3137.24
0
10
20
30
40
50
1998 1999 2000 2001 2002 2003 2004 2005
Alcohol Use of Driver Injured in Transport Accident
in Khon Kaen Municipality %
80.372.773.0
70.174.179.5
88.0
66.171.761.1
65.861.7 59.965.775.2
55.249.141.549.245.8
36.737.2
49.141.2
3.11.92.62.62.82.42.22.2
0.0
20.0
40.0
60.0
80.0
100.0
0 - 0.25 0.25 - 0.5 0.5 - 0.75 0.75 - 1.0
Dead Rate by Severity Classified by TRISS
1998 1999 2000 2001 2002 2003 2004 2005
%
Utility of trauma registryUtility of trauma registry
Traffic Injured Patients Data for Insurances Traffic Injured Patients Data for Insurances Office every morningOffice every morning
Public ServicePublic Service
Trauma AuditingTrauma Auditing Medical AuditMedical Audit Nursing AuditNursing Audit Referral AuditReferral Audit EMS AuditEMS Audit ER AuditER Audit
Utility of trauma registryUtility of trauma registry
Trauma preventionTrauma prevention
Provincial Safety Committee review Provincial Safety Committee review situation monthly situation monthly
Medical Institute for Injury and Medical Institute for Injury and Disaster Disaster
Epidemiology Department ; MOPHEpidemiology Department ; MOPH
MonitoringMonitoring
Study and ResearchStudy and Research
Ps Ps = 1/1+e= 1/1+e-b-b
PsPs = Probability for survival= Probability for survival
ee = 2.7183 (base on Napierian logarithms)= 2.7183 (base on Napierian logarithms)
bb = b0+b1(= b0+b1(RTSRTS)+b2()+b2(ISSISS)+b3()+b3(AA))
RTSRTS = Revised Trauma Score= Revised Trauma Score
ISSISS = Injury Severity Score= Injury Severity Score
AA = 1 if age >54= 1 if age >54
= 0 if age <54= 0 if age <54
Severity Assessment Severity Assessment TRISS MethodologyTRISS Methodology
1.1. GCSGCS
2.2. Blood pressureBlood pressure
3.3. Respiratory rateRespiratory rate
4.4. ISSISS
5.5. AgeAge
6.6. Mechanism of injuryMechanism of injury
The Variable for Calculation of PsThe Variable for Calculation of Ps
Trauma AuditingTrauma Auditing Medical AuditMedical Audit
Nursing AuditNursing Audit
Referral AuditReferral Audit
EMS AuditEMS Audit
ER AuditER Audit
Recent ApplicationRecent ApplicationRecent ApplicationRecent Application
• Trauma registryTrauma registry
• Medical recordMedical record
• Trauma audit recording formTrauma audit recording form
• Guideline for recording data and Guideline for recording data and definitiondefinition
• Peer group reviewPeer group review
Component for Trauma AuditComponent for Trauma Audit
Hospital Trauma Audit Committee Assessment IHospital Trauma Audit Committee Assessment I
Hospital Trauma Audit Committee Assessment IIHospital Trauma Audit Committee Assessment II
• LeaderLeader• Peer groupPeer group
– SurgeonSurgeon– Neuro SurgeonNeuro Surgeon– CVTCVT– AnesthetistAnesthetist– OrthopedistOrthopedist
• CoordinatorCoordinator
Peer ReviewPeer Review
• Set up committeeSet up committee
• Set up the content for auditSet up the content for audit
• Set up the coordinatorSet up the coordinator
• Committee meetingCommittee meeting
• Design the time, date, place for reviewDesign the time, date, place for review
• Peer group reviewPeer group review
• Analyze and reportAnalyze and report
Technique for AuditTechnique for Audit
Death Rate of Patient Death Rate of Patient Classified by Severity of Injury in 1994Classified by Severity of Injury in 1994
PsPs NumberNumber DeathDeath PercentPercent
0.00-0.250.00-0.25 8989 8080 89.989.9
>0.25-0.50>0.25-0.50 7575 4949 65.365.3
>0.50-1.00>0.50-1.00 2,5462,546 8888 3.53.5
Before Audit Filter ApplicationBefore Audit Filter Application
Grouping for Type of Mortality Grouping for Type of Mortality by Trauma Audit Committee in 1994by Trauma Audit Committee in 1994
Type of MortalityType of Mortality NumberNumber DeathDeath %%
Non-preventable deathNon-preventable death 8585 7676 89.489.4
Potentially preventable deathPotentially preventable death 8585 5959 69.469.4
Preventable deathPreventable death 2,5402,540 8282 3.23.2
Before Audit Filter Application Before Audit Filter Application
Trauma Care ImprovementTrauma Care Improvementby Participatory Action Researchby Participatory Action Research
IdentifyingProblem
UnderstandingCause
ImplementationSuggesting
Solution
Evaluation
IdentifyingProblem
UnderstandingCause
ImplementationSuggesting
Solution
Evaluation
Trauma Audit for Trauma Service Development Trauma Audit for Trauma Service Development 1994 –19951994 –1995
Identifying Problem Understanding Cause
Implementation
Suggesting SolutionEvaluation
Team TR
Trauma Registry
TRISS table (Ps>0.5: MR=3.5)
TA Committee
Dead case review- Preventable dead rate (3.2%)- Factor for MM.
Audit filter committee
Audit filter setting
Audit filter (1 ed.)
TA committee
Implementation
Process modification
TA committee
Evaluation
Ps>0.5 : MR=2.8%
Preventable dead rate = 2.7%
Evaluation of Trauma Audit Project 1996Evaluation of Trauma Audit Project 1996
Identifying Problem Understanding Cause
Implementation
Suggesting SolutionEvaluation
TA committee
Seminar and discussion
Preventable dead rate was still high
- Practical limitation in some
iterm of audit filter
- Limit to only surgeon
- Unknown compliance
- System inadequacy was not
solvedTA committee
Evaluation
Ps>0.5 : MR=2.8%
Preventable dead rate = 2.7%
Identifying Problem Understanding Cause
ImplementationSuggesting SolutionEvaluation
Preventable dead rate wasstill high
Ps > 0.5 MR 94 = 3.5% MR 95 = 2.8%Pv dead rate 94 = 3.2%
95 = 2.7%
- Practical limitation in some item of audit filter
- The project limit to only surgeon
- System inadequacy was not solved
Process, Khonledge System
Medical Audit FilterCommittee
Audit Filter Setting
Medical Audit Filter(2nd ed.)
Nursing Audit FilterCommittee
Audit Filter Setting
Nursing Audit Filter
Patient care leadteam
Brain strom forsolution
Solution
Quality Improvement Team - Doctor - Nurse
Implementation
Process System Modification
TA Committee
Evaluation
Ps > 0.5 MR 97 = 2.7%Pv dead rate 97 = 2.1%
Medical and Nursing Audit for the Management Medical and Nursing Audit for the Management of Traumatic Patient 1997 - 1998of Traumatic Patient 1997 - 1998
Study on PerformanceStudy on Performance
FollowingFollowing
the Key Performance Indicatorthe Key Performance Indicator
for Trauma Carefor Trauma Care
Khon Kaen HospitalKhon Kaen Hospital
Study on PerformanceStudy on Performance
FollowingFollowing
the Key Performance Indicatorthe Key Performance Indicator
for Trauma Carefor Trauma Care
Khon Kaen HospitalKhon Kaen Hospital
Witaya ChadbunchachaiWitaya Chadbunchachai
Trauma and Critical Care CenterTrauma and Critical Care Center
Khon Kaen HospitalKhon Kaen Hospital
Conceptual Frame WorkConceptual Frame WorkConceptual Frame WorkConceptual Frame Work
• Set up system of medical care quality Set up system of medical care quality assessmentassessment
• Auditing system - dead case peer reviewAuditing system - dead case peer review
• Set up audit filterSet up audit filter
• ImplementationImplementation
• EvaluationEvaluation
Problems in Previous ProjectsProblems in Previous Projects
• Completeness of audit filterCompleteness of audit filter
• Cooperation of personnelCooperation of personnel
KPIs enhanced the efficiency of trauma care.KPIs enhanced the efficiency of trauma care.
Copes :[ J. Trauma 1995;38:432-438]Copes :[ J. Trauma 1995;38:432-438]
Performance IndicatorPerformance Indicator
:- Statistic that reflected the quality :- Statistic that reflected the quality of care process leading to outcomes.of care process leading to outcomes.
Performance ManagementPerformance Management
:- Method that manages personnel to :- Method that manages personnel to comply with KPIs.comply with KPIs.
ObjectivesObjectivesObjectivesObjectives
• Establishing the KPIs for trauma careEstablishing the KPIs for trauma care
• Establishing the Performance Establishing the Performance Management System for personnel in Management System for personnel in trauma care to comply with KPIstrauma care to comply with KPIs
MethodMethodMethodMethod
1. Preparation1. Preparation
– KPIs establishmentKPIs establishment• Committee making KPIsCommittee making KPIs• Review by 3 expertsReview by 3 experts
– System for performance managementSystem for performance management• Computer program for collecting dataComputer program for collecting data• Collecting data teamCollecting data team• Various formVarious form
(March - April 2000)(March - April 2000)
2. Implementation2. Implementation
– Meeting and trainingMeeting and training– CMECME
• Morning reportMorning report• Case conferenceCase conference• MM conferenceMM conference• X-ray conferenceX-ray conference
– OrientationOrientation– Solving problem of system inadequacySolving problem of system inadequacy
(May - June 2000)(May - June 2000)
MethodMethodMethodMethod
3. Outcome Study3. Outcome Study
(July - December 2000)(July - December 2000)
Inclusion Inclusion - all trauma admission- all trauma admission- all trauma dead- all trauma dead
ExclusionExclusion - underlying disease- underlying disease
EvaluationEvaluation - Preventable dead rate- Preventable dead rate- Performance rate- Performance rate- Compare result with 1995, - Compare result with 1995, 19981998
MethodMethod
4. Analysis4. Analysis
(January - June 2001)(January - June 2001)
MethodMethod
ResultsResultsResultsResults
1. Number of trauma patients1. Number of trauma patients
NoNo Admit Admit Dead Dead
Jul - Dec 1994Jul - Dec 1994 8,578 8,578 2,732 2,732 217 217
Mar-Aug 1995Mar-Aug 1995 7,967 7,967 2,492 2,492 206 206
Sep 97-Feb 98Sep 97-Feb 98 6,953 6,953 2,233 2,233 165 165
Jul - Dec 2000Jul - Dec 2000 8,984 8,984 2,747 2,747 127 127
2. Trauma audit committee dead case peer review2. Trauma audit committee dead case peer review
Type Non Preventable PotentiallyPreventable
Preventable Total
No Dead % No Dead % No Dead % No Dead %
1994 89 76 85.4 75 59 87.7 2546 82 3.2 2710 217 8.0
1995 113 94 83.2 62 50 80.6 2317 62 2.7 2492 206 8.2
1998 106 99 93.3 35 23 65.7 2091 42 2.0 2232 164 7.3
2000 110 78 70.9 42 14 33.3 2595 35 1.3* 2747 127 4.6
* Statistical significant* Statistical significant
ResultsResultsResultsResults
3. Pitfall in the management of trauma patient3. Pitfall in the management of trauma patient
Year Type of Pitfall
Delay DxNo/C
ErrorDx
No/C
Error RxNo/C
ErrorTechnique
No/C
SystemInadequacy
No/C
TotalNo/C
1994 10/10 24/14 222/164 12/10 139/67 407/265
1995 13/9 8/7 172/136 19/15 89/50 301/217
1998 6/4 7/5 73/46 8/5 67/26 161/86*
2000 3/- 12/3 102/67 18/14 21/4 156/88
C = Contribute to deadC = Contribute to dead * = Statistic significant* = Statistic significant
ResultsResultsResultsResults
4. Performance Rate4. Performance Rate
KPI TotalNo
Yes % Threshold
1. In ER >2 hr 2638 55 2.1 0
2. Exceed 2000 cc V without blood 79 42 53.2 20
3. Explore penetrating wound > 1 hr of arrival 65 33 50.8 20
4. Spend time for CT > 1 hr 108 29 26.9 20
5. GCS < 13 no CT with in 4 hr 458 57 12.4 10
6. GCS < 9 intubution within 10 min 105 97 92.4 100
7. Multiple injury no CXR 283 52 18.4 20
ResultsResultsResultsResults
ResultsResultsResultsResults
KPI TotalNo
Yes % Threshold
8. Blunt injury above clavicle no C-spine XR 723 224 31.0 20
9. Blunt injury above clavicle no collar 674 190 28.2 20
10. Multiple injury no O2 278 11 4.0 0
11. Represent in ER within 72 hr 2683 11 0.4 0
12. Missed fracture 1428 6 0.4 0
13. Hypothermia 2681 2 0.1 0
14. Fracture fixation within 48 hr of arrival 950 791 83.7 80
4. Performance Rate4. Performance Rate
ResultsResultsResultsResults
KPI TotalNo
Yes % Threshold
15. Compound fracture fixation within 8 hr 439 117 26.7 80
16. Non therapeutic laparotomy 107 3 2.8 20
17. Time to craniotomy
< 2 hr 144 3 2.1
2 – 4 hr 144 23 16.0 80
>4 hr 144 118 81.9
18. Jt dislocation Rx > 4 hr 56 12 21.4 80
4. Performance Rate4. Performance Rate
4. Performance Rate4. Performance Rate
KPI TotalNo
Yes % Threshold
19. Laparotomy in PT with BP<90 in 60 min 32 7 21.9 80
20. Time to laparotomy
< 2 hr 144 49 43.0
2 – 4 hr 144 27 23.7 80
>4 hr 144 38 33.3
21. Rx ischemic limb in 4 hr 6 2 33.3 80
22. Unplanned return to OR 641 19 3.0 5
ResultsResultsResultsResults
ResultsResultsResultsResults
KPI TotalNo
Yes % Threshold
23. Unplanned return to ICU 48 2 4.2 5
24. Hct < 25% during admission 2603 15 5.8 10
25. Document T in OR 1612 1 0.1 80
26. All injury Dx in 24 hr 2671 2620 98.1 99
27. Complication 2683 267 10.0 10
4. Performance Rate4. Performance Rate
1. Establishing the KPIs for trauma care is a 1. Establishing the KPIs for trauma care is a major step in improving the quality of caremajor step in improving the quality of care
2. Key success is to make all personnel 2. Key success is to make all personnel understand and willing to practice the KPIsunderstand and willing to practice the KPIs
Discussion
Medical and Nursing Audit for the Management of Traumatic patient 1997-1998
Identifying Problem
Room for improvement of Preventable deathPs>0.5 MR 94=3.5% 95=2.8% 97=2.7%PV MR 94=3.2% 95=2.7% 97=2.1%
Understanding Cause
Completeness of audit filterCooperation of personnel
Establishing KPIEstablishing performancemanagement
ImplementationPs>0.5 MR 00=2.0%PV MR 00=1.3%
Suggesting SolutionImplementationEvaluation
Referral AuditReferral AuditReferral AuditReferral Audit
Result of Referral Development, Khon Kaen Hospital, Result of Referral Development, Khon Kaen Hospital, 1997-20001997-2000
Procedure Adequate Inadequate No
97 %
98 %
99 %
00 %
97 %
98 %
99 %
00 %
97 %
98 %
99 %
00 %
Airway 54.7 59.9 67.6 77.8 12.9 14.2 6.9 7.7 32.5 25.9 25.5 14.4
Stop bleeding
53.0 54.3 69.7 67.6 31.2 37.0 24.4 27.3 15.8 8.7 6.0 5.2
Splint 43.9 48.3 51.9 53.6 28.3 32.5 27.1 22.9 27.7 19.2 21.0 23.5
IV fluid 83.1 43.2 89.3 86.2 6.5 5.9 10.5 8.5 10.5 8.5 4.8 5.3
First Aid Care of EMT and VolunteerFirst Aid Care of EMT and VolunteerFirst Aid Care of EMT and VolunteerFirst Aid Care of EMT and Volunteer
Procedure Care No Care
Proper Improper
97
%
98
%
99
%
00
%
97
%
98
%
99
%
00
%
97
%
98
%
99
%
00
%
1. Volunteer
Airway care 1.1 0 0 9.1 2.9 7.2 5.3 0 90.0 92.8 94.7 90.9
Stop bleeding 4.5 2.5 5.5 13.2 9.8 7.0 7.4 9.6 85.7 90.5 87.1 77.2
Splint/slab 3.7 9.5 9.4 27.5 6.4 9.0 14.4 7.2 80.9 81.5 73.2 65.4
IV fluid 7.0 5.3 4.9 6.0 0.8 4.1 1.2 0 92.2 90.6 93.9 94.0
2. EMT
Airway care 30.2 33.3 70.0 68.3 7.0 11.1 0 4.9 62.8 55.6 30.0 26.8
Stop bleeding 23.3 37.2 45.5 63.9 22.5 15.4 14.7 12.0 54.2 47.4 39.8 24.0
Splint/slab 30.8 50.0 67.1 80.4 7.7 6.7 9.1 3.4 61.5 43.3 23.7 16.2
IV fluid 37.7 37.2 22.7 22.7 1.4 1.9 0 4.5 60.9 61.1 77.3 72.7
IS Table 31 IS Table 31 Number of Patient treated at ER >2 hr.Number of Patient treated at ER >2 hr.
IS Table 31 IS Table 31 Number of Patient treated at ER >2 hr.Number of Patient treated at ER >2 hr.
Year
Time
1997
No. (%)
1998
No. (%)
1999
No. (%)
2000
No. (%)
00.00-07.59 31 (8.7) 62 (9.1) 43 (3.9) 83 (7.1)
08.00-15.59 55 (7.2) 83 (5.9) 109 (4.7) 149 (6.2)
16.00-23.59 40 (4.8) 71 (4.5) 65 (2.6) 89 (3.5)
Total 126 (2.9) 216 (5.9) 217 (2.9) 321 (3.4)
Traffic Injury Cost classified by severity in 5 area based (2004)
Area basedBaht/case Baht/accident
Dead Disability Severe MinorProperty
damage
Average 3,395,551 3,617,150 122,591 30,247 40,161
Bangkok 6,191,330 6,322,792 253,689 135,471 128,300
Others (average of 4 regions) 3,241,150 3,548,514 115,933 23,181 31,145
North 2,602,575 2,789,470 114,661 23,030 31,081
Central 3,710,683 4,252,905 116,760 23,294 31,164
Northeast 2,553,037 2,725,961 114,991 23,058 31,184
South 3,364,576 3,602,481 116,202 23,191 31,067
Traffic Injury Cost classified by severity in 5 area based (2004)
Area Based
Dead Disability Severe Minor Property damage Total
Million baht %
Million baht %
Million baht %
Million baht %
Million baht %
Million baht %
Bangkok4,618.7
17.6 1,429.0 5.4 2,660.9 25.2 6,608.7 10.1 10,958.3 41.7 26,275.7 100
North 3,464.0 26.1 2,669.5 20.1 2,543.4 13.6 1,797.1 19.2 278.0 21.0 13,262.0 100
Central 24,260.4 34.5 16,650.1 23.7 10,596.4 10.6 7,436.3 15.1 11,431.8 16.2 70,375.1 100
North-east 9,173.1 26.0 6,994.8 19.8 6,840.8 13.7 4,825.4 19.4 7,501.8 21.2 35,335.9 100
South 6,883.9 29.7 5,299.3 22.8 396,074.0 12.0 2,780.6 17.1 4,282.1 18.5 23,206.6 100
Total 48,400.2 28.7 33,042.7 19.6 2,660,229.0 13.9 23,448.1 15.8 36,962.1 21.9 168,455.3 100
EFFECTIVE KNOWLEDGE TRANSFER EFFECTIVE KNOWLEDGE TRANSFER
REQUIRES THE RECIPIENT TO NOT ONLY REQUIRES THE RECIPIENT TO NOT ONLY
HAVE A NEED BUT ALSO A DESIRE TO HAVE A NEED BUT ALSO A DESIRE TO
MEET THAT NEED; IT NEEDS THEIR MEET THAT NEED; IT NEEDS THEIR
HEARTS AS WELL AS THEIR MINDS.HEARTS AS WELL AS THEIR MINDS.
B.J. Campbell, 1998B.J. Campbell, 1998
Global Traffic Safety TrustGlobal Traffic Safety Trust
Your Committee motivationdelication
to make to happen make a difference
Peter Davison
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